Long-term Outcomes of Childhood Sexual Abuse

BACKGROUND

• Prevalence of CSA is reported to be higher among girls than boys (18.0 to 20.0% vs. ~8%), however, determining accurate prevalence figures is difficult. [Stoltenberg et al 2011]
• The severity of the injury, type of abuse suffered, the measure of psychological distress and symptoms, and future clinical diagnoses differ between females and males. [Amado et al 2015]
• Male CSA victims take on average 10 years to discuss their experience, which is considerably longer than that for female CSA victims; this difference may be influenced by society’s traditional view of men as aggressors and not victims.
• Alternatively, some boys may not view a CSA experience with an older woman as abuse due to sex stereotypes. Furthermore, boys that were abused by an older man may believe they would be regarded as homosexual due to cultural beliefs.
• It is estimated that CSA is more prevalent in Africa than in Europe although cultural beliefs across countries and continents can affect estimations. [Pereda et al 2009]
• The highest mean prevalence of CSA in males and females was in South Africa – 60.9% and 43.7% respectively.
• For instance, collectivist cultures can hinder CSA disclosure so as to protect the family from a sense of shame whereas individualistic cultures may support and encourage a CSA disclosure. [Stoltenberg et al 2011]
• Furthermore, the definition of CSA also affects prevalence rates. Firstly, it is influenced by subjective perception and secondly by parameters such as the cut-off age and minimum age difference between victim and perpetrator.
• A broad definition will, therefore, include non-contact (i.e. propositioning or exhibitionism) whereas a narrow definition would include contact-only abuse.

LONG TERM OUTCOMES

It is postulated that CSA can disrupt a child’s sense of self, which results in interpersonal and emotional abnormalities as well as difficulties in coping with stress. [Cole and Putnam 1992]

Furthermore, research suggests that CSA causes epigenetic modifications and the induction of long-lasting abnormalities to a child’s HPA axis and increases inflammation. [Danese and Baldwin 2017]

Since PTSD can occur in the context of a highly traumatic event, it is postulated that CSA is likely to result in an outcome that is associated with long-term psychosocial, psychiatric, and physical disorders. [Molnar et al. 2001]

However, not all CSA sufferers will develop PTSD, as shown in a longitudinal cohort study, which reported that only 38% of individuals who experienced CSA, developed PTSD. [Dube et al. 2003]

An umbrella review of the literature searched multiple databases to determine the long-term health-related consequences of CSA [Hailes et al. 2019]. 

In this review, the following disorders were associated with CSA:

• Psychiatric outcomes – Schizophrenia, somatoform disorders, eating disorders, PTSD, MDD, anxiety, borderline personality disorder, and conversion disorder. [Read more on Complex PTSD]
• Psychosocial outcomes – Unprotected sex, sex work, sex with multiple partners, substance abuse, suicidal, self-injury, adult sexual re-victimisation, and sex offending against children or adults
• Physical outcomes – Obesity, HIV, pain, and fibromyalgia

The researchers then calculated the odds ratios (ORs) and compared the association between CSA and psychiatric, psychosocial, and physical health outcomes. Overall, the effect sizes could be modelled between the following ORs:

Psychiatric odds ratios

• The ORs were between 2.2 (95% CI: 1.8–2.8) and 3.3 (95% CI: 2.2–4.8) with conversion disorder, borderline personality disorder, anxiety, and depression having the strongest associations with CSA.

Psychosocial odds ratios

• The ORs were between 1.2 (95% CI: 1.1–1.4) and 3.4 (95% CI: 2.3–4.8) with the strongest association for sexual offending versus non-sexual offending.
• All other psychosocial outcomes showed statistically significant increased odds.

Physical health odds ratios

• The ORs were between 1.4 (95% CI: 1.3–1.6) and 1.9 (95% CI: 1.4–2.8), and the strongest associations were with pain (continuous) and fibromyalgia. CSA is also considered to be a premorbid risk factor for the development of Chronic Fatigue Syndrome. [Van Den Eede et al., 2012]

Among these long-term outcomes, there were only two associations that were derived from high-quality meta-analyses: PTSD and substance abuse.

Assuming causality, population attributable risk fractions for outcomes ranged from 1·7% for unprotected sexual intercourse to 14·4% for conversion disorder.

Therefore, treatment modalities for PTSD may be indicated for individuals who have experienced CSA. [Learn more about the diagnosis and management of PTSD]

LONG TERM TREATMENT

It has been previously reported that the overt symptoms of CSA are fear, anxiety, and depressive moods and therefore, these are often the focus for treatment. [Gilbert et al. 2009]

However, the trajectory of symptoms is likely to change over time and is also likely to be influenced by the form of abuse experienced:

• Pre-school children – Anxiety, nightmares, externalising behaviour, and inappropriate sexual behaviours
• School-aged children – School problems, hyperactivity, and nightmares
• Adolescents – Depression, generalised anxiety, suicidal or self‐injurious behaviour, or substance misuse.

To treat and manage children who have been abused, research suggests that cognitive behavioural interventions for children with PTSD should be indicated. [Ramchandani and Jones 2003; Macdonald et al. 2012]

CBT focuses on the meaning of the events for the child and non-offending parent(s) and aims to address maladaptive cognitions, self-esteem, and misattribution of blame.

In the treatment of children who have been sexually abused, cognitive‐behavioural approaches focus on the meaning of events for children and non‐offending parents, endeavouring to identify and address maladaptive cognitions (for example, being permanently ‘soiled’), misattributions (for example, feelings of blame and responsibility) and low self‐esteem.

In addition, interventions drawn from operant, respondent and observational learning paradigms are used to address more overtly behavioural problems such as externalising behaviours (aggression or ‘acting out’), internalising behaviours (anxiety, self‐blame or deprecation) or sexualised behaviour, usually mediated through the involvement of a parent not responsible for the abuse.

Trauma-focused CBT conceptualises the effects of CSA as a consequence of trauma and aims to reduce emotional distress, behavioural problems and anxiety symptoms. [Macdonald et al. 2012]

There are limitations in the evidence base, and further research is needed to establish the effectiveness of CBT. The target components in therapy include:

• Emotional distress – Modest effect size on depression, PTSD, and anxiety in children.
• Behavioural problems – There is little evidence that there is a beneficial effect on sexualised behaviour and externalising behaviour (e.g. aggression) in children.
• Parent skills – Significantly improved the parent(s)’ belief in their child’s story and the emotional reactivity of the parent(s) (e.g. fear, sadness, guilt, anger, embarrassment, shame and emotional preoccupation).

CONCLUSION

CSA is associated with a wide range of psychiatric, psychosocial, and physical symptoms, and these can develop into disorders that can persist into adulthood.

CBT shows potential as a treatment however, the evidence base is limited.

The prevention of CSA is a more important strategy for reducing associated psychopathology.